Inspection on 18/08/05 for Northmead House

This inspection was carried out on 18th August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Northmead House 19/07/07

Northmead House 22/05/06

Northmead House 20/12/05

Northmead House 23/11/04

Northmead House 25/06/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Northmead 3 Northmead Puriton Bridgwater Somerset TA7 8DD Lead Inspector Judith Roper Unannounced 18th August 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Northmead D53 -D02 S42169 Northmead V244808 180805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Northmead Address 3 Northmead Puriton Bridgwater Somerset TA7 8DD 01823 423126 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Somerset County Council (LD Services) Ms Clare Lois Marks Personal Care Home Only 10 Category(ies) of Learning Disability registration, with number Physical Disbability of places Northmead D53 -D02 S42169 Northmead V244808 180805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Registered for up to 10 persons in category LD who may have a concurrent physical disability. 2. Registered for respite care placements only. Date of last inspection 23rd November 2004 Brief Description of the Service: Northmead House is a large detached house situated in the village of Puriton. The home provides respite care for adults who have a learning or physical disability. Appropriate adaptations have been provided within the home to meet service users needs. There is an enclosed garden at the rear of the property. Northmead House is run by Social Services. The Registered Manager is Mrs Clare Marks and the Responsible Individual is Mr David Dick. Northmead House is registered with the Commission for Social Care Inspection to provide short stay accommodation for up to ten people who have a learning or physical disability. Northmead D53 -D02 S42169 Northmead V244808 180805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out by one inspector and took place over one day between the hours of 10.00 am – 3.45 pm. 7 residents were at the home on the day of the inspection. There are currently 3 vacancies at the home. The inspector was able to interact with 3 residents. 6 residents went out at times during the inspection visit. There were no relative visitors at the home during the inspection visit. Staff on duty were able to give time to speak with the inspector. The registered manager Ms. Marks is on sick leave but the support worker coordinating the shift helped the inspector carry out the inspection. At the close of the inspection the deputy manager was on duty and the inspector was able to give the deputy inspector feedback of her inspection findings. The inspector would like to thank the staff for their time and hospitality shown to the inspector during her visit. The atmosphere at the home was relaxed and informal. Staff carried out their duties in a friendly and professional manner. It was a pleasantly warm summers day and several residents had the opportunity to go out of the home with staff or day centre escorts. This is the first inspection using the new CSCI reporting format, which focuses on outcome statements for National Minimum Standards. The inspector’s aim on this inspection visit was to seek views on the quality of the service from as many service users as possible and to speak to staff and any visiting relatives. Records examined during the inspection were resident care and support plans, the fire log, two resident contracts, staffing rosters, resident risk assessments, staff fire training records and medication records; other records will be examined at subsequent inspection visits. What the service does well: What has improved since the last inspection? At the last unannounced inspection in November 2004 7 requirements and 2 recommendations were made. The two requirements made regarding completion of records in residents care and support plans have been met. The Northmead D53 -D02 S42169 Northmead V244808 180805 Stage 4.doc Version 1.40 Page 6 requirement that the home does not breech its conditions of registration is currently being complied with. There are 3 residents who have been at the service for over three months but the CSCI has been consulted with this. The requirements made with regard to residents meal preference recording has been met, as has the requirement to provide liquid soap and hand towels in the laundry. The requirement made to risk assess residents utilising bed rails has not been met. The requirement made to help improve medication management has been met, although there still remain concerns about the management of medication at the home. Of the two recommendations made at the last inspection the home is in the process of ensuring photographic identification of residents on their medication charts (MARs). The home is meeting the recommendation that opened medications are labelled with a discard date. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Northmead D53 -D02 S42169 Northmead V244808 180805 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Northmead D53 -D02 S42169 Northmead V244808 180805 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4,5. Northmead is a respite facility. Therefore there is a high turnover of resident numbers. The home therefore needs to be robust in obtaining pre-admission assessments. This was satisfactory at this inspection visit. The home sometimes takes emergency admissions and recently has had residents stay longer than the intended three month respite stay due to waiting for suitable alternative accommodation to be found. Information available for residents before admission is appropriate and available in Somerset Total Communication. EVIDENCE: The home has a Statement of Purpose and a copy of this is held at the local CSCI office. There is a guide for residents, which is also produced in Somerset Total Communication. The home is registered to provide respite care services for a maximum of 10 persons. 7 people were admitted to the service on the day of the inspection. 3 people have stayed at the home longer then the intended 3 month respite provision. This is outside of the condition of registration but was not intended and the home has informed the CSCI when this has happened. Admission records were inspected for 2 current residents. There was evidence of placement authority pre-admission assessments and assessments of need completed by the home in anticipation of admission. Many residents are Northmead D53 -D02 S42169 Northmead V244808 180805 Stage 4.doc Version 1.40 Page 9 regular users of the respite service at Northmead. This means that staff employed at the home are able to know the needs of these residents well. A visit to the home pre-admission is encouraged. 2 current resident’s contracts were inspected. These were in order. Northmead D53 -D02 S42169 Northmead V244808 180805 Stage 4.doc Version 1.40 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7,8,9,10. Care and support plans for individual residents were detailed and holistic. Evidence of review was not sufficiently clear. Risk assessments for individual residents were completed for a variety of identified hazards but not stored for ease of access for staff. Risk assessments for the use of bedrails had not been completed. This is required as bedrails are a form of restraint that needs justifying and pose a risk of entrapment if not fitted appropriately. Routines at the home are flexible and tailored to resident’s daily commitments. Resident confidentiality is maintained at the home. EVIDENCE: Care and support plans were maintained for all current residents. Information held within plans was tailored to individual need. Care and support plans were completed in 2005 and showed evidence of update and review. It was not clear when reviews and updates had taken place as staff had not always signed or dated reviews. This is required. Risk assessments had been completed for a variety of individuals’ needs but some risk assessments were filed and stored in the office and not in individual care and support plans. It is recommended that individual’s risk assessments be stored in care and support plans for staff accessibility. 3 current residents have bedrails fitted to their beds for health Northmead D53 -D02 S42169 Northmead V244808 180805 Stage 4.doc Version 1.40 Page 11 and safety reasons. The use of bedrails has not been risk assessed. This is required. The home is auditing the safe fitting of bedrails monthly. Further advice was given to staff to help them appreciate the purpose of auditing bedrail fitting in terms of entrapment risk or bedrail accidental collapse and injury to the resident. Resident personal possessions brought into the home were recorded. Routines at the home are flexible and tailored to residents continuing to access community leisure or educational placements committed to prior to the respite stay at the home. The home has a Confidentiality policy. Records relating to staff and residents are stored securely in accordance with Data Protection principles. Northmead D53 -D02 S42169 Northmead V244808 180805 Stage 4.doc Version 1.40 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11,12,13,14,15,16,17. The home is enabling respite residents to continue accessing the day care, activities and educational commitments made prior to admission to the home. Those residents that have stayed beyond three months have an activity programme devised for them in addition to community commitments. Family and carer relationships are supported and maintained. Staff assist residents in maintaining these relationships whilst respite care is being accessed. Meals are flexible and residents likes and dislikes are known. The fridge in the home is faulty and must be replaced to ensure that food storage is safe. Some staff need a routine training update in food handling. This has been booked in. EVIDENCE: The home aims to provide residents with the opportunity to continue accessing the services that they would normally access from home. This is being achieved. Residents are continuing to also access day services whilst staying at Northmead. This helps to provide consistency of care and routine for the Northmead D53 -D02 S42169 Northmead V244808 180805 Stage 4.doc Version 1.40 Page 13 people accessing respite at the home. The three people who have stayed at the home for more than three months also have an activity plan tailored to individual need. This includes evening activities detailed in individual care and support plans. Northmead has a vehicle to provide transport for residents into the local community. In the village of Puriton there is a village shop within walking distance of the home. Due to the nature of the service provided, there is considerable contact with families and carers. The home has an open visiting policy. Contact with relatives or carers are documented in care and support plans. Routines at the home are flexible to individual daily needs. Residents can hold a key to their room if they wish. There is a four week running menu. A choice of main meal is offered. Shopping for food is locally sourced. The dining facilities at the home are congenial and provide sufficient space for residents and staff to assist at meal times. Records are kept of residents’ meal likes and dislikes. Staff record fridge and freezer temperatures daily. The fridge in the kitchen has been running approximately on average 4 degrees above the optimal temperature for around two weeks and that the fridge is faulty. It was reported that property services for Somerset Partnership have been informed and a replacement fridge has been requested. It is required that a replacement fridge be provided. Several staff require an essential food hygiene update. It was reported that these staff have been booked into a course to rectify this. At the next inspection the staff training files for food hygiene training will be followed up. Northmead D53 -D02 S42169 Northmead V244808 180805 Stage 4.doc Version 1.40 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19,20. Staff are providing individualised and sensitive support to residents but if the staff call bell system were working this would provide more independence and dignity for residents. Community health care is accessed and documented with outcomes. Residents are continuing to receive health support as they would normally expect whilst receiving respite care at Northmead. Medication management remains poor. Somerset Partnership is investigating this in order to improve the situation. EVIDENCE: During the inspection staff were observed interacting with residents in a sensitive and friendly manner. Staff were communicating with residents in a language that they understood. Staff are trained in Somerset Total Communication. Three residents spoken with indicated that the home was friendly and that staff were nice. There is a call bell system in the home but it is not working. In order to maximise resident’s independence and dignity it is required that call bells are operational in bathrooms and toilets and in bedrooms of residents who would be able to operate the staff call bell system. Northmead D53 -D02 S42169 Northmead V244808 180805 Stage 4.doc Version 1.40 Page 15 Nursing care is not provided at the home. Community nurse support is accessed if need is assessed and identified. This is recorded in the individual’s care and support plan. Resident’s retain their own GP whilst using the respite service at Northmead. A record is maintained in care and support plans of health care appointments accessed from the home and of outcomes. Some current residents are monitored at night via a baby monitor system due to clinical risks. This was documented in individual care and support plans with evidence of consultation with parents. It is recommended that there be a fuller explanation of why a person needs to be monitored by a listening device a night. The current consultation document gives a general health and welfare explanation. In order to justify the invasion of privacy of a resident the home should provide a precise explanation to families explaining clinical need. Medication systems were inspected. There have been three recent medication errors at the home and the CSCI has been notified of these. Somerset Partnership is currently investigating medication management at the home in order to work with the home’s management and staff to improve safe medication management at the home. The CSCI is assisting with this. During the inspection medication administration records of prescription only medicines were recorded satisfactorily. Recording of controlled drugs was not. The home must have a current reference medication book in the home. The British National Formulary (BNF) medication reference book was more than 4 years old. It is required that a current BNF be obtained for the home for staff to refer to. No residents currently manage their own medications. Medications are stored in a secure area in individual resident’s rooms. In order for staff to monitor the recommended maximum temperature of medications stored in bedrooms it is recommended that thermometers be provided in the secure cupboards in bedrooms. There is an on-going difficulty for staff in identifying some medications brought into the home from parents of residents when medications arrive not in their original dispensed packaging. The staff are aware that for safety they cannot dispense medication for residents that is not provided in the original packaging from the dispensing pharmacy. The home’s network manager has said that she will write again to families of respite users stressing that staff will not dispense medication that cannot be safely identified and that a person’s respite stay may be jeopardised if medication does not arrive at the home in the required packaging. The CSCI supports the Partnership in this sensible stance. Northmead D53 -D02 S42169 Northmead V244808 180805 Stage 4.doc Version 1.40 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) EVIDENCE: Complaints and adult protection were not inspected in detail at this inspection. Somerset Partnership NHS (the provider) is investigating a complaint made in the home that is an adult protection issue. The Partnership has informed the CSCI and will be sharing findings with the CSCI. The home displays its’ complaints procedure, also available in Somerset Total Communication, in the home. Northmead D53 -D02 S42169 Northmead V244808 180805 Stage 4.doc Version 1.40 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,25,26,27,28,29,30. The environment is attractive and offers a range of communal space. There are good facilities for physically disabled residents. The home was clean to a high domestic standard on the day of the inspection. The management needs to consult with the local fire service regarding hindering access from the first floor fire escape route during night hours in order to demonstrate that staff and residents are not put at undue risk. The management also needs to address hand washing facilities for staff attending to resident personal care at the home. Present facilities are not sufficient to adequately mange the risk of cross contamination in the home. EVIDENCE: Pleasing accommodation at the home is provided over two floors. There is a passenger lift at the home. All bedrooms are for single occupancy and are of a good size. Two ground floor bedrooms have overhead hoists available. All but one bedroom has en-suite facilities. Two rooms do not have lockable facilities for valuables provided and this is made a requirement as a result of the inspection visit. The standard of decoration and furnishing is good. Outdoor space is attractive and offers privacy from the road. Northmead D53 -D02 S42169 Northmead V244808 180805 Stage 4.doc Version 1.40 Page 18 The home plans to alter the current arrangement of placing at night a hinged bar at the top of the first floor landing to a barrier of more sturdy design in order to prevent any residents from falling down the stairs at night. The inspector has recommended that the home management consults the local fire service on this matter as the stair case is on a designated fire escape route and the route could be compromised at night when the barrier is in place. It was not clear during the inspection if the fire service had been consulted when the original stair barrier was installed. There are two assisted bathrooms and one shower room. Toilets are accessible for wheelchair users. Facilities for physically disabled residents are good in the home. Communal areas comprise of a lounge, dining room and a quiet room. The main lounge would be a little cramped if all residents and staff used it at one. Staff on duty during the inspection said that this would be an unlikely occurrence. There is sufficient compensatory communal space provided. There is provision at the home for staff on sleeping-in duties. The sleeping-in room also includes an en-suite for staff. The laundry facilities and laundry infection control equipment is sufficient. COSHH is handled appropriately. Hazardous chemicals used in the home were appropriately stored. Residents assisting with domestic cleaning in the home do so under staff supervision. The domestic standard of cleanliness in the home was high on the day of the inspection. There are not sufficient facilities in the home for staff to wash their hands after attending to personal care with residents. There must be provided liquid soap, paper hand towels and flip to bins in resident communal bathrooms and toilets. The same arrangements must be provided in bedrooms of any residents who receive assistance with personal care from staff in order to manage the risk of cross infection and infection control in the home. It is also recommended that the home management contact the local Health Protection Unit for advice regarding the amount of waste generated in the home from the management of incontinence. The Health Protection Unit may advise that the home needs to set up a clinical waste contract as the amount produced is exceeding domestic household amounts. Northmead D53 -D02 S42169 Northmead V244808 180805 Stage 4.doc Version 1.40 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,36. Staffing levels in the home are sufficient to provide personalised individual care for residents. Whilst the manager is on sick leave provision has been made for additional managerial support on a part-time basis for the deputy manager. Staff are supervised and this is a formal process, allowing them to have 1:1 time with their supervisor to discuss work progress and work issues. EVIDENCE: Staffing rotas were seen by the inspector. Staffing levels in the home vary to the number of current residents. Staffing levels allow for 1:1 support of residents. Staff spoken to said that staffing levels in the home were provided in sufficient numbers for them to give enough unrushed time and attention to residents. Staff understood the value and benefit of regular supervision. Generally the staff team receives individual supervision with a senior colleague six weekly. There has been a slight tail off in this frequency recently due to the manager’s sickness but the staff supervision is hoped to return to normal soon with the support of a manager from another home on a part-time basis whilst the home manager is on sick leave. Northmead D53 -D02 S42169 Northmead V244808 180805 Stage 4.doc Version 1.40 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 40,42. There are generic and local policies in the home for staff at Northmead to access. The policies are accessible for staff although staff on duty did not know where the medication policy produced by Northmead for the home was stored. Fire system maintenance and staff fire training by in-house fire marshals was appropriately and clearly maintained. EVIDENCE: The home uses generic polices and procedures for all homes in Somerset Partnership social services establishments. Northmead also has produced some policies individual to the service. Northmead is visited by the designated network manager for the Partnership at least monthly. A report is produced of the network manager’s findings. Fire log records were inspected and these were maintained in good order. Fire safety equipment in the home was checked and serviced at appropriate Northmead D53 -D02 S42169 Northmead V244808 180805 Stage 4.doc Version 1.40 Page 21 intervals. Staff fire training records appeared to be complete. In earlier chapters in this report are findings relating to other health and safety issues; risk assessment recording, bed rails, fire escape routes, medication, infection control and food handling. Northmead D53 -D02 S42169 Northmead V244808 180805 Stage 4.doc Version 1.40 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 2 3 3 Standard No 22 23 ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 3 2 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 2 3 3 3 1 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 2 Standard No 31 32 33 34 35 36 Score x x 3 x x 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Northmead Score 2 3 1 x Standard No 37 38 39 40 41 42 43 Score x x x 3 x 3 x D53 -D02 S42169 Northmead V244808 180805 Stage 4.doc Version 1.40 Page 23 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 17 (3) (a) Requirement It is required that staff reviewing residents care and support plans date and sign when plans have been reviewed in order for it to be clear when the plan has been reviewed or updated. The home must ensure that a risk assessment is completed prior to bed rails being used for any service user staying within the home. This must be reviewed each time they are readmitted to the service. Evidence of consent from the individual or if unable to consent then consultation with family members must be recorded. The kitchen fridge that is faulty must be replaced. A suitable call bell facility must be provided in communal bathrooms and toilets and in bedrooms of residents assessed as benefiting from being able to summon staff of their own volition. This would promote residents dignity and independence at the home. Controlled drugs must be stored appropriately and stock levels recorded in a bound numbered Timescale for action 18/9/05. 2. YA9 13 (4) (b) & (c) 18/9/05. (Timescale of 17/12/04 not met). 3. 4. YA17 YA18 16 (2) (g) 12 (4) (a) 18/09/05. 18/12/05. 5. YA20 13 (2) 18/09/05. Northmead D53 -D02 S42169 Northmead V244808 180805 Stage 4.doc Version 1.40 Page 24 6. YA26 16 (2) (l) 7. YA30 13 (3) 8. YA30 16 (2) (k) & 23 (5) book on a daily basis. The home needs to obtain a current British National Formulary (BNF). Lockable storage facilities for the safe storage of residents valuables must be provided in the two bedrooms lacking this facility. Liquid soap, paper hand towels and a flip top bin must be provided in all communal bathrooms, toilets and in ensuites of residents who receive staff support for personal care. This is in order to provide adequate infection control facilties in the home. It is required that the home consults with the Health Protection Unit in Taunton regarding clinical waste disposal of incontinence products. The home may need to secure a clinical waste contract if the amount of incontince waste at Northmead exceeds normal domestic levels. 18/10/05. 18/09/05. 18/09/05. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA9 Good Practice Recommendations It is recommended that risk assessments for individual residents be stored in the individuals care and support plan rather than the homes office file for immediate staff access. It is recommended that where the home utilises surveilance devices (baby monitors) for the health and safety of individual residents, that the consultation/consent form provded to residents/relatives be more explicit to why the home believes that a listening device should be used. It is recommended that thermometers be provided in the D53 -D02 S42169 Northmead V244808 180805 Stage 4.doc Version 1.40 Page 25 2. YA18 3. YA20 Northmead 4. YA24 lockable storage areas for medication in resident rooms. Staff would then be able to monitor that the temperature in the storage facilities does not exceed 25 degrees Celcius and therefore optimal storage temperatures for medications therein. It is recommended that the home consults with the local fire service regarding the plan to further restrict at night the first floor stair case, which is situated on a designated fire escape route. Northmead D53 -D02 S42169 Northmead V244808 180805 Stage 4.doc Version 1.40 Page 26 Commission for Social Care Inspection Riverside Chambers Castle Street Tangier Taunton TA1 4AL National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Northmead D53 -D02 S42169 Northmead V244808 180805 Stage 4.doc Version 1.40 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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